Bulletins

June 2000

This Bulletin is forwarded to every medical practitioner in the province. Decisions of the College on matters of standards, amendments to Regulations, guidelines, etc., are published in Bulletins. The College therefore assumes that a practitioner should be aware of these matters.

--------------------------------------------

Officers and Councillors 1999-2000

President - Dr. Beatriz Sainz, Oromocto
Vice-President - Dr. Christine Davies, Saint John

Dr. Pamela Walsh, Riverview
Dr. Bill Martin, Miramichi
Dr. Ludger Blier, Edmundston
Dr. Marc Panneton, Campbellton
Dr. Marc Bourcier, Moncton
Dr. Gordon Mockler, Westfield
Dr. Zeljko Bolesnikov, Fredericton
Registrar - Dr. Ed Schollenberg


Dr. Nataraj Chettiar, Beresford
Dr. Rudolph Stocek, Hartland
Dr. Douglas Brien, Saint John
Mr. Eugene LeBlanc, Dalhousie
Mr. Fernand Rioux, Caraquet
Dr. Claudia Whalen (PhD), Fredericton
Ms Janet McIntosh, Moncton




At its meetings on 9 June 2000, Council considered the following matters:

Dr. X
A physician was to perform two procedures on two different patients. The procedures were somewhat similar, and the patients were of a similar age. He relied on his own "booking" list to determine which patient was to have which procedure. Unfortunately, his own list had the patients in the wrong order. The first patient, thus, had the wrong procedure. The matter was relatively easily corrected, although the patient had to be anaesthetized a second time. There was no evidence of any long-term effect. The physician acknowledged the error and made specific changes in his procedures. To a charge of performing a procedure without consent, he admitted professional misconduct. In an agreement with the Council, he was issued a reprimand without publication of his name.

Complaints:
An elderly, somewhat confused, patient fell out bed after a surgery. The patient was seen by the attending physician, who found no evidence of significant injury. Some weeks later, it was determined that the patient had fractured her hip. On review, the Committee noted that the original procedure occurred near the hip and seemed to be causing pain on its own. Furthermore, the patient demonstrated some level of confusion. Finally, the Committee noted that the principal concerns expressed by the family were against the nursing coverage. The Committee could find no fault with the care provided by the physician.

An infant presented in the Emergency Department with a history of spitting up and some difficulty breathing. On review by the physician, the main concern appeared to be on the spitting up. As the examination concluded, it became clear that the mother was much more worried about the child's breathing and requested a chest x-ray. The physician did not feel such was warranted, but ordered one anyway. The x-ray was initially interpreted as negative, but, on subsequent report, an infiltrate was found. The complaint was that the physician had inadequately assessed the patient. On reviewing the matter, the Committee felt that the physician's assessment was appropriate for the clinical situation. Nevertheless, it was clear that the mother had a great deal of anxiety about her child. The physician may have been somewhat more sensitive to these issues. However, the Committee did not feel there were any shortcomings in the care provided.

A patient had two skin lesions removed. The wounds healed poorly and the patient was unhappy with the level of scarring. On reviewing the clinical care provided, there appeared to be no deficiencies. There were medical indications for removing the lesions, but, in the Committee's view, the patient may have been more concerned with a cosmetic benefit. Physicians should ensure that patients have reasonable expectations of the results of any such treatment. A patient raised several complaints regarding her family physician; particularly that he rushed through her visits, and that he did not respond to her specific problems. In a detailed response, the physician asserted that all appropriate concerns were addressed. The Committee felt this was the kind of patient who would expect, and may need, a considerable amount of time. This is both to address the patient's needs and to demonstrate that they were being addressed. Other than making that observation, the Committee did not feel there were any deficiencies in care.

It was alleged that there had been an unnecessary delay in the investigation of a child's headaches. The initial mention of the headaches to the physician was as a secondary complaint. Some months later, the headaches had increased in frequency and were associated with vomiting. There was also some suggestion that they were worse when the child missed meals. The physician felt they were likely migraine. A neurological examination was not done. Two months later, the headaches were increasing in frequency and appeared to be present on waking. Some initial investigations were done, but it was a few weeks before referral and a CT Scan were arranged. It was found that the child had a significant brain tumor. The allegation was that the physician had not appropriately responded to the symptoms and signs as they had developed. On reviewing the matter in detail, the Committee felt that, overall, the physician's response to the developing situation was appropriate. Inevitably, with any progressive disease, there will be a period of time where diagnosis will be difficult. From the physician's point of view, even if a diagnosis cannot be reached, efforts should be made to respond appropriately to the particular clinical situation at that point in time. For example, an early neurological examination would have been normal in this case, but would have offered support for the physician's actions if they are subsequently questioned.

A very elderly patient was injured in a nursing home. She had repeatedly refused examination and treatment in the past. Two physicians were contacted who recommended various approaches. Through the nurses, some family members appeared to confirm that there was to be no specific treatment. A fracture was subsequently discovered and treated. Other family members felt that the physicians had not responded appropriately. On reviewing the matter, the Committee did note that the physicians had not directly assessed the patient, although there was reason to believe that such would not have gained very much. Furthermore, the Committee did feel that it might have been better if there had been direct contact with the physicians and the family, as opposed to such only occurring through the nurses. Nevertheless, from a clinical point of view, the Committee felt that the care provided was appropriate.

After a relatively uneventful pregnancy and labour, a child was born following a low forceps delivery. The baby was severely depressed and not breathing spontaneously. Resuscitation was prolonged and, in fact, the baby never recovered, dying a few months later. On reviewing the matter, the Committee could find no evidence that there was fetal distress any earlier than had been apparent to the physician, nor could the Committee find any place where anything different could have been done. Despite the condition of the baby, the care provided appears to have been appropriate.

The family of a suicide victim complained that the patient had been inadequately assessed. On reviewing the matter, the Committee noted that past history had suggested a risk of suicide. Nonetheless, the physician had made significant recommendations regarding a medication change and follow-up care. The patient was offered admission, but refused. There was no clear reason for an involuntary admission. For all of these reasons, the Committee felt that the care provided was appropriate.

The son of an elderly patient complained regarding the care provided by his mother's family physician. He alleged that there were unnecessary appointments and a general lack of response to her clinical condition. A detailed response from the physician demonstrated, in the Committee's view, that there had been appropriate follow-up and investigation of all relevant matters. There was also no evidence that the patient herself was unsatisfied with the care provided.

There was a complaint from the patient of a psychiatrist that the care provided was inappropriately demeaning and judgmental. On reviewing the response of the psychiatrist, and considerng the patient's psychiatric condition, the Committee felt that the patient's interpretation of events were largely influenced by her own pathology. The Committee could find no fault with the care provided.

Laboratory and Other Reports
Recent litigation in New Brunswick and other provinces has concerned the question of the physician's obligation to track and retrieve diagnostic reports and forward relevant information to the patient. Even though some responsibility for a missing report may be attached to a hospital or diagnostic facility, courts have consistently assigned most of the responsibility to the physician who orders the test. Courts appear to acknowledge that, in any complex system, reports can go astray. For that reason, courts have also expected that physicians have developed a "system" of some type to minimize such a risk. Council feels that physicians should review their own practices in the context of these developments.


Consultants Reports

Council has become increasingly concerned regarding the practice of some consultants in failing to report back to the referring physician, or to delay doing so by several months. Council does not feel a specific policy on the matter is necessary, but physicians are reminded of the risks involved in such practice. Communication with a referring physician is an integral part of the consultative process. Potential risks to patient care of such delayed communication are obvious. Furthermore, should the consultant claim for a full consultation before reporting to the referring physician, there is a risk of breaching College regulations, which preclude billing for a service not performed. Council hopes that recognizing these issues, as well as a sense of common professional courtesy, will reduce this problem.

Firearms and Suicide
As a result of the suicide of a New Brunswick patient in Quebec, the Chief Coroner of Quebec has requested that physicians be reminded of the importance of inquiring regarding the ownership or access to firearms for patients who present with mental health disorders, including major depression, where there is a risk of suicide.

"One Problem per Visit"
There have been increasing concerns raised with the College regarding the practice of some physicians precluding the consideration of any more than a single problem in an office visit. In some cases, this involves the posting of signage stating this policy. At other times, the patient is asked to book a sequence of appointments in advance to deal with each issue. Physicians have been accused of simply walking out on a patient who wishes to raise another matter. At other times, the physician, upon being presented with two problems, has requested that the patient decide which one will be dealt with on that visit. It is also reported by some patients that they have been advised that the physician is "not allowed" to deal with more than one problem.

Council notes this raises several questions. Is this approach consistent with contemporary attitudes to treating the "complete" patient? Is there a risk that significant issues will not be addressed if it is left to the patient to determine which problem presents the greatest risk? Can an aging population be effectively dealt with in this fashion? If communication difficulties are the source of most complaints, will such an approach potentially increase complaints? What impact does the fee schedule, providing family physicians with a single available code for an office visit, have on the matter?

Council wishes to canvass members on this. Please feel free to forward any comments by any means available.

Elections
Recent elections for Council have been concluded. New members of Council are Dr. Malcolm Smith of Tracadie-Sheila and Dr. Robert Rae of Saint John. As reported earlier, elected by acclamation were Dr. Ludger Blier of Edmundston and Dr. Marc Panneton of Campbellton.

Immunization Records
It has been reported to the College that some physicians, on the basis of confidentiality, are resisting disclosing immunization records to public health officials. After reviewing the matter, Council feels it appropriate to advise physicians that the usual confidentiality rules do not apply to immunization records. Physicians should be free to disclose such in response to any bona fide request for information.

Public Members
There are currently four members of the public on the Council of the College. They are appointed by the Minister of Health and Wellness from a list of names submitted by the Council. There will shortly be a vacancy among the public members. If physicians are aware of any individuals who may be suitable to fill such a position, their names should be forwarded to the College.

ES/cm